Barriers and facilitators of health professionals in adopting digital health-related tools for medication appropriateness: A systematic review

Objective Digital health is described as the use and development of all types of digital technologies to improve health outcomes. It could be used to prevent medication errors, a priority for health systems worldwide. However, the adoption of such tools remains slow. This study aims to identify factors (attitudes, knowledge and beliefs) acting as barriers and/or facilitators reported by healthcare professionals (HCPs) for the adoption of digital health-related tools for medication appropriateness. Methods A systematic review was performed by searching the literature in the MEDLINE PubMed, and EMBASE scientific databases for original articles regarding qualitative and quantitative data. Results Fifteen articles were included and a total of 125 barriers and 108 facilitators were identified, consolidated and categorized into technical (n = 48), organizational (n = 12), economical (n = 4), user-related (n = 34), and patient-related (n = 8) components. The most often reported barriers and facilitators were technical component-related ones concerning the need for additional training (n = 6), the time consumed (n = 6), and the easy way of using or learning how to use the tools (n = 9), respectively. Regarding setting analysis, agreement with clinical decision recommendations and impact on the doctor–patient relationship were more valued in primary care, while the user interface and system design were in the hospital. Conclusions The barriers and facilitators identified in this study provide relevant information to developers and it can be used as a starting point for the designing of successful digital health-related tools, specifically related to medication appropriateness. Future research includes economic evaluation-focused studies and in-depth case studies of specific barriers and facilitators.


Introduction
Digital health is understood as the use and development of all types of digital technologies to improve health outcomes, 1 encompassing eHealth (information and communication technologies), mHealth (mobile health) and big data. 2The widespread use of health information technology has become one of the main strategies to improve the efficiency, accessibility, quality and safety of health systems, clinical decision making, and medication management, helping to avoid errors at ordering and prescribing stages. 3,4In fact, in one study, the likelihood of medication errors in hospitals decreased 48% when a prescription drug order was performed through a computerized provider order entry (CPOE) system. 57][8][9] Currently, more than 350,000 health applications are available, and 250 new ones are released every day. 10Data showed that 58.23% of smartphone users in the United States used and downloaded health-related applications. 11These tools could have several beneficial functionalities such as support for clinical diagnosis or decision making, patient adherence, or simply providing education. 12It is estimated that the digital health market should reach nearly 660 billion dollars by 2025. 13][16][17][18] In addition, the widespread of digital health could help to eliminate health disparities worldwide. 19espite the advantages presented above, the adoption of digital health-related tools remains slow. 20,21As the digital era emerges, major changes in HCPs' workflow arise, sometimes with a lack of regulation or guidelines, which has led to many HCPs remaining reluctant to adopt digital health technologies. 22,23Important knowledge gaps related to digital health education were also identified, reinforcing the need for wider support for HCPs. 24reviously, one study found that only five of 280 diabetes mobile applications evaluated were associated with clinically meaningful improvement, revealing that clinical effectiveness is not always guaranteed. 25 Addressing factors that could hamper or promote the adoption of digital health-related tools can help to create technologies that better meet the needs of HCPs and provide patients with higher-quality care. 24,26Therefore, preferences of end-users should be considered for the technology design.HCPs will benefit from clinically meaningful digital solutions, while healthcare systems will need to obtain financial returns or save costs by acquiring digital health technologies. 27Therefore, to improve digital health adherence, an understanding of barriers and facilitators that can influence the adoption and use of digital tools by HCPs is the first step required.
Previous reviews on barriers and facilitators for the implementation of eHealth or mHealth in general, 21 or the acceptance of medication-related CDSS, 28 or in a specific setting 29,30 showed the following as the most reported barriers and facilitators: time consuming, 28,29 security and privacy concerns, 21,23,31 limited knowledge and literacy, 21,31 weakened communication and interaction with others, 23,29 and financial support 21,23,31 as barriers; ease of use, 21,23,28 and equipment availability and reliability 21,28,29 as facilitators.However, there is a lack of systematized information on the barriers and facilitators for the use of the various digital tools available to support the appropriate use of medicines.Challenges to the implementation of such technologies should be studied; therefore, with our review, we aim to expand previous findings by covering all types of digital health-related tools for medication appropriateness and to identify factors that are reported by HCPs to act as barriers and/or facilitators in the adoption of digital health-related tools for medication appropriateness.Therefore, outcomes from this systematic review will add more reliable information to the existing body of evidence for developers and all stakeholders involved in the design and creation of successful digital health-related tools.

Material and methods
To provide a comprehensive understanding more useful for clinical decision making and health care decision makers, and to help researchers focus on the most relevant barriers and/or facilitators when developing any types of digital health-related tools, we performed a systematic review following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines (Table S1). 32The research protocol is registered on PROSPERO (CRD42022363235).

Search strategy
A literature search was conducted on 28 October 2022 on the MEDLINE PubMed and EMBASE scientific databases for articles published since 1 January 2000.The search strategy intended to identify relevant studies addressing barriers and/or facilitators identified by HCPs in adopting digital health-related tools for medication appropriateness, using the following broad-based search terms strategy: "(barrier OR facilitator OR attitudes OR beliefs OR knowledge) AND (adopt OR adoption OR implementation*) AND (health professional OR health provider OR clinician OR physician OR GP OR general practitioner OR nurse OR pharmacist) AND (digital health-related tool OR digital health tool OR mobile health OR mhealth OR m-health OR electronic health OR ehealth OR e-health OR telehealth OR clinical decision support system OR computerized clinical decision support system) AND (medication appropriateness OR drug appropriateness OR appropriate medication OR inappropriate medication OR inadequate prescription OR quality prescription OR adequate prescription)" (Table S2).The reference list of relevant articles and the author's files were also searched to identify potential additional articles (snowballing technique).

Study selection
The following inclusion criteria were applied: (i) studies that identify factors (such as attitudes, knowledge, and/or beliefs) acting as barriers (factors hampering) or facilitators (factors promoting) in the adoption of digital health-related tools for medication appropriateness; (ii) studies directed to HCPs in any healthcare context (also including studies in which HCPs are a part of a heterogeneous sample when the data are presented separately for HCPs); (iii) studies that did not have investigating barriers and facilitators to be a mandatory aim; (iv) studies reporting the results of primary data; (v) studies published in Portuguese, English, or Spanish.For this review, an HCP was considered as any individual who requires a degree qualification to practise in their respective healthcare field and to provide healthcare treatments and advice based on formal training and experience. 33e excluded studies that do not present an analysis of barriers or facilitators as an outcome, reviews, meta-analyses, opinions, letters to the editor that do not provide original data, comments, reports, protocols, duplicate studies and the grey literature.We excluded usability studies, as these look more to analyse system-specific usability problems rather than barriers and facilitators.Studies that analyse electronic prescribing systems which do not address medication appropriateness were also excluded.Studies that identify barriers and facilitators but did not associate them with the intention of HCPs to adopt or use digital health-related tools were excluded.
Two researchers (DR and MR) independently screened all titles and abstracts retrieved from the databases according to the inclusion criteria and evaluated the eligibility of full-text articles.All discrepancies were resolved through discussion with the help of a third researcher (MTH, AF or FR).

Outcome measures
Our primary outcome measure was the data establishing the specific barriers and/or facilitators reported by HCPs in adopting digital health-related tools for medication appropriateness.

Quality assessment
The quality and susceptibility to bias were independently evaluated by two researchers (DR and MR) for each included study.The Mixed Methods Appraisal Tool (MMAT) version 2018 was used to assess the quality of qualitative, quantitative, and mixed methods studies. 34,35ll discrepancies were resolved through discussion with a third researcher (MTH, AF or FR).

Data extraction
Data were extracted from all studies by two authors (DR and MR) using a data extraction sheet.Data on authors (year), country, study design, setting, sample size, health professionals' category, methods of data collection, digital health tools, description of tools, types of treatments/ drugs, and patients' subgroups were extracted from each article included.Further data about barriers and facilitators were extracted and analysed.

Data analysis
We defined a barrier as a factor hampering the adoption of digital health-related tools and a facilitator as a factor promoting the adoption of digital health-related tools.Barriers and/or facilitators extracted from the included studies were independently analysed by two researchers, and grouped into the following categories: (i) technical, concerning all barriers and/or facilitators related to digital health tools itself and the associated technology and training; (ii) user-related, including all aspects related to the behaviours, concerns and feelings of HCPs; (iii) economical, aspects associated with costs, funding, financial incentives and/or reimbursement; (iv) organizational, including all barriers and/or facilitators related to the organizational structure and support in which digital health tools are integrated (or where it's supposed to be); (v) patient-related, including all concerns related to the patient and the quality of care provided.Discrepancies were resolved through discussion with the help of a third researcher.This analysis was conducted for each category concerning barriers and/or facilitators, regardless of the authors' categorisation.The quotes transcribed in the included studies were also analysed.Subgroup analyses were conducted for the types of barriers and facilitators, and setting (hospital and primary care).

Study selection
The search of the databases yielded 1340 citations by systematically searching the literature in the scientific databases MEDLINE PubMed (n = 1312) and EMBASE (n = 28).After screening titles and abstracts, 13 duplicated articles were removed, and four were added using the snowballing technique.A total of 1327 articles were screened and 87 potentially met the inclusion criteria.Since six articles were not retrieved, only 81 articles were fully screened.Among these articles, 66 were excluded because they did not present an analysis of barriers or facilitators as an outcome (n = 14), did not address medication appropriateness (n = 49), did not present primary data (n = 1), and did not associate barriers and/or facilitators with the intention of HCPs to adopt or use digital health-related tools (n = 2) (Table S3).[38][39][40][41][42][43][44][45][46][47][48][49][50]

Barriers and facilitators related to the use of digital tools on medication appropriateness
In the 15 included studies, 125 barriers and 108 facilitators were identified.After they were consolidated, 59 unique different types of barriers (Table 3) and 47 unique different types of facilitators (Table 4) were obtained.Among the barriers, 24 were classified as technical, 22 were userrelated, one was considered economical, nine were  organizational, and three were patient-related.Regarding facilitators, 24 were of the technical category, 12 were userrelated, three were considered economical, three were organizational, and five were patient-related.Barriers and facilitators according to each study can be found in Table S4.
Technical barriers and facilitators.43,48 Less reported ones were the lack of connection with other medical software (n = 2), 39,41 the lack of customizability (n = 2), 38,41 the low specificity of the alerts (n = 2), 41,47 and the lack of well-integrated functions in the system (n = 2).47,50 The remaining technical barriers were reported only one time.
50 The less reported ones were the agreement with the clinical decision recommendations (n = 2), 39,43 the familiarity with the system and the technology (n = 2), 44,46 the improvement of communication between HCPs (n = 2), 47,50 and the system meeting expectations (n = 2).44,49 The remaining user-related facilitators were reported only one time.
Economic barriers and facilitators.Only one economic barrier was reported concerning the lack of funding and/ or financial incentives (n = 5). 36,39,46,47,50egarding economic facilitators, the most cited was the improvement of cost-effectiveness (n = 2). 36,37Financial incentives (n = 1) 47 and adequate budgeting (n = 1) 48 were the least reported ones.
Only three organizational facilitators were reported, the possibility to accommodate practice workflow (n = 1), 43 the possibility of non-medical staff having access to the system (n = 1), 43 and the willingness to invest greater resources in the future (n = 1). 46tient-related barriers and facilitators.Three patient-related barriers were described, the willingness to change according to the medication priorities of the patient (n = 1), 39 patients' cooperation in changing medication (n = 1), 39  and the inconvenience to use the system for patients with multiple complaints (n = 1). 43he most cited patient-related facilitator was the improved quality of care provided to patients (n = 2). 44,49he remaining ones were only reported once.

Setting analysis
Alert fatigue, the time consumed, and the ease of use were common technical barriers and facilitators among primary care 36,[39][40][41]44 and hospitals 37,38,45 (Table S5). Tr38][39]45 However, some differences were also found. Regardinthe technical component, HCPs valued the need for training (n = 3) in primary care 36,41,43 and the poor user interface and system design (n = 2) was more outlined in hospitals.38,45 While in primary care, the lack of internet was an organizational barrier (n = 2), 39,43 medico-legal issues and liability were most reported in hospitals (n = 2).37,45 Negative impact on the doctor-patient relationship (n = 3) and lack of trust in the system (n = 3) were user-related barriers in primary care, 36,39,41,44,46 while in hospitals, HCPs gave more importance to the end-user unfamiliarity with the device and technology (n = 2).37,42 Finally, besides the trust in the system, HCPs also reported the encouragement to reflect on their practice (n = 2), 36,39 the agreement with the clinical decision recommendations (n = 2) 39,43 and the commitment to use the system (n = 2) 43,46 as userrelated facilitators in primary care for the adoption of digital health-related tools.

Discussion
Our review revealed that there are more barriers than facilitators in the adoption of digital health-related tools for medication appropriateness, suggesting that there is a lot of work to be done.The included studies mostly reported barriers and facilitators related to the technical component of the tool, more specifically, the need for additional training and the time consumed as barriers, and the easy way of using or learning how to use it as a facilitator.
HCPs do not want to waste time that could be spent with patients during the consultation with a digital tool that requires too much additional work rather than simplifying it, 41,51 possibly lowering the quality of care provided. 37[47][48][49][50] To overcome the need for training and the time needed for technology adoptation, user-centred approaches concerning literacy needs, skills, and capabilities should be developed and incorporated into the design of digital health technologies. 52ligned with our findings, a previous systematic review about barriers and facilitators for the acceptance of medication-related CDSS identified the time consumed as the most reported barrier, and the ease of use as the most reported facilitator. 28Similar results were found in one study with a specific focus on digital health technology adoption for hypertension management 53 and in EHR adoption by physicians. 51User-friendliness was also reported as one of the most important factors identified by patients and clinicians about digital technology regarding cardiovascular care, 54 and as the most important predictor of the implementation of eHealth services and digital health technologies. 21,55Our results corroborate with a recently published overview of systematic reviews, which found that infrastructure and technical issues are a source of concern for HCPs in utilizing digital health technologies. 56o surpass such constrains, digital tool developers should guarantee that user interfaces are intuitive, and technical support is properly supplied. 57Investment in infrastructure upgrades may also be necessary to improve equipment and network connections.
Regarding user-related barriers and facilitators, end-user unfamiliarity with the device and technology was reported as a barrier to the adoption of new technologies.Reluctance to change and the lack of trust in the system were also important barriers reported by HCPs since they may be accustomed to traditional methods, resisting to embrace digital technology. 58User-friendly interfaces and well-designed digital tools that guarantee long-term sustainability and maintenance are essential for HCPs to integrate these tools into their daily practice, even without extensive technical knowledge. 19,27Besides, as a facilitator, the recommendations provided by these technologies can represent an opportunity for HCPs to reflect them in their practice and to consider alternative treatment options, leading to more informed decision making and making their practice even more patient-centred. 59he improved quality of care provided to the patient was also reported as one patient-related facilitator.On the other hand, inconvenience to use such tools in patients with multiple complaints was reported as one patient-related barrier, maybe due to the complexity of their health conditions and the need for a more comprehensive assessment and care plan. 60Therefore, a digital tool must be flexible.Sometimes patients can also resist to medication changes; however, digital health technologies could help to improve treatment adherence and completion. 61Reaching patient cooperation requires effective communication and education by HCPs.
Concerning the organizational domain, medico-legal issues and liability were reported as barriers.This could be related with misdiagnosis or errors such as providing inaccurate information, diagnostic suggestions, or treatment recommendations which could lead to patient harm, implying that digital tools may face liability claims. 62Otherwise, the growing recognition of significant benefits that technology can bring to healthcare increases the willingness to invest greater resources in digital health-related tools. 58he barriers and facilitators identified in our review aligned with existing models and frameworks theorizing user adoption of new technologies including: the Theory of Planned Behaviour (TPB), 63,64 in which perceived behavioural is determined by the perceived availability of resources, opportunities and skills (like user unfamiliarity with the device and technology, or difficulties navigating through the system); the Theory of Interpersonal Behaviour (TIB) 64,65 and the Social Cognitive Theory (SCT), 64,66 with emotions, social and environment factors and habits being identified as the main factors influencing the intention to use (such as societal trend and the increase in clinicians' own confidence); the Technology Acceptance Model (TAM), 64,67 reflected in the perceived ease of use and attitude toward use; the Motivational Model (MM), 64,68 being the improvement of the quality of care provided a motivation factor for the adoption of the digital tool for medication appropriateness.
Regarding the setting, most differences between primary care and hospitals are related to the technical component of the digital tool and user-related barriers and facilitators.In primary care, medication-related digital tools provide information to HCPs at the point of care for decision making and direct intervention. 69Therefore, agreement with the clinical decision recommendations and the impact on the doctorpatient relationship are very important factors. 70Besides, the relationship between HCPs and patients is one of the main factors influencing the delivery of good therapy and high-quality care. 71In hospitals, medication-related digital technology is directed towards therapeutic drug monitoring and clinical calculators, 42,45 explaining why user interfaces and system design were more valued.A previous systematic review focused on hospital setting identified hardware and network problems, such as malfunctions and cumbersome access procedures, slow systems, and poor functionality as key barriers for the implementation of electronic systems for the prescribing, dispensing and administration of medicines. 29Also, it had already been reported that HCPs working in hospitals have the perception that CDSS may be used against them in the event of medicolegal controversies. 72Clear documentation and legal protection when using digital tools is advised.
The studies included in this review are reported in different years, with up to 20 year of difference, and it is possible to perceive that some barriers and facilitators remain over time.6][77] Funding challenges could be related to the cost of purchasing the system, expensive equipment, installation charges and staff training costs, among others. 36,39,46,47,50,76nfortunately, an insufficient level of sustainable funding is an enormous obstacle to implementing digital health technologies. 21,78,79Knowledge about digital health outcomes is essential to overcome this barrier, 1 with designing and planning for longitudinal cost analysis at the outset. 80herefore, investment should be directed towards reducing these barriers and enhancing the facilitators when developing tools and with interventions adapted to cultural and sociodemographic differences.Regarding facilitators, HCPs continue to give the same importance to the ease of use of systems, the capacity to trust in digital tools, and the encouragement to reflect on their practice. 36,50Having a system that easily adapts to the needs and capabilities of HCPs is a timeless quality.]45,50,81 Digital health systems can be a source of information that could support reflective practice and behaviour change of HCPs, 82 and make the decision to prescribe a more conscious process. 36,39,50This is closely related to the educational role technical facilitator also identified in this study, since the alert information provided may educate the HCP about a potential interaction or prompt him/her to look up more information or confer with a colleague. 36,47,50ver the last 20 years, most of the studies were conducted in Europe, showing that the impact of digital tools for medication appropriateness on health was not well documented, especially in African countries.Despite reports of the use of mobile phones, and information and communication technologies to improve public health in developing countries, 83 its application remains slow and inequitable, far from being high. 84This could be related to the lack of HCPs in these countries, the high cost of technology implementation, unstable power supply, the excessive burden of diseases 85 or the limited access to digital technologies. 85,86However, according to the WHO Global Strategy on Digital Health, there is an urgent need to invest and overcome the major obstacles felt by developing countries in engaging and accessing digital health technologies. 1Therefore, a commitment and engagement with stakeholders are needed to advance digital health in these countries.
8][89] The high use of CDSS can also be explained by its capacity to develop multiple functions beyond medication reconciliation, such as computerized guidelines, order sets, patient data reports, documentation templates, and clinical workflow tools. 80hey can also be found in different ways such as desktops, tablets, smartphones, biometric monitoring, and wearable health technology.Furthermore, CDSS can be costeffective for health systems. 80ith this study, we intend to give relevant information to developers and to all stakeholders for the creation and implementation of digital health-related tools for medication appropriateness.The strengths of this review also include the cross-checking of the reference lists of the included studies to avoid missing papers, and the independent and duplicate process of the screening, data extraction, and quality assessment.Besides, we made a reflection on differences regarding types of barriers and facilitators, and between settings.However, some limitations are also present.Firstly, a search in grey literature was not performed.However, we believe that it does not influence our results since the grey literature is not peer reviewed and is not indexed in major bibliographic resources.Secondly, the search strategy was limited to articles written only in English, Portuguese, and Spanish.Besides, the included studies were heterogeneous concerning digital health-related tools, although most studies used CDSS; the description can be variable in each study.Furthermore, medication appropriateness is generally understood as a guarantee that a specific medication is chosen as the most suitable, effective, and safety option aligned with the individual patient's specific clinical and healthcare needs, minimizing adverse effects and improving therapeutic outcomes. 90,91However, authors of the different studies included in this systematic review may have a different definition.
Despite the limitations presented, we believe that our main findings are pertinent.The data collected assessed the barriers and facilitations identified by HCPs for the adoption of medication-related digital tools, adding reliable information for all stakeholders, from developers to policymakers, allowing them to develop and implement useful and friendly health technologies, and to contribute to the improvement of services and healthcare.

Conclusion
The barriers and facilitators identified in this study can be used as a starting point by developers and all stakeholders involved in the design and creation of successful digital health-related tools.The results suggest that the main barriers are related to usability and technical issues, user attitudes and perceptions, and infrastructure challenges; adherence to digital tools can be facilitated by practice support, userfriendly design and functionality, and quality improvement.The implementation of such tools should mostly follow a technical and user-centred approach, being easy-to-use essentially for HCPs without being time-consuming.
Future research is needed on economic evaluationfocused studies to surpass barriers and to better invest resources in medication-related digital tool development and implementation.In-depth case studies of specific barriers and facilitators should also be conducted.

Figure 1 .
Figure 1.PRISMA diagram of the literature selection in this systematic review.
CDSS: clinical decision support system; CMR: comprehensive medication review; COPD: chronic obstructive pulmonary disease; CPOE: computerized physician order entry; EHR: electronic health record; EMR: electronic medical record; GP: general practitioner; HCP: healthcare professionals; MDSS: medication decision support system; MEDS: medicine electronic decision support; N: nurse; Pharm: pharmacist; PharmT: pharmacy technicians; Phys: physician; PhysA: physician assistant; UK: United Kingdom; USA: United States of America a Studies in which HCPs are a part of a heterogeneous sample but it is possible to distinguish their concrete opinions; the sample size reported corresponds only to HCPs.

Table 2 .
Quality assessment of the included studies through the mixed methods appraisal tool (MMAT) version 2018.